- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $281.84 / $660.69
| Professional | | $100.00 | $281.84 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $660.69 / $1,348.96
| Professional | | $407.38 | $660.69 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $338.84 / $616.60 / $2,041.74
| Professional | 50 | $338.84 | $616.60 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $229.09 / $512.86
| Professional | | $154.88 | $229.09 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $295.12 / $3,090.30
| Facility | | $257.04 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $363.08 / $831.76
| Professional | | $181.97 | $363.08 | $831.76 |